Hospital Compliance With Federal Price Transparency Requirements: A Review of Madison, Wisconsin Hospitals

Background

As of January 1, 2021, hospitals must comply with the “Hospital Price Transparency Final Rule,” requiring them to make their standard charges available to the public. Charges must be provided in two formats:

“1. A comprehensive machine-readable file that includes all standard charges for all hospital items and services; and

2. A consumer-friendly display of standard charges for at least 300 ‘shoppable’ services that are grouped with charges for ancillary services that are customarily provided by the hospital.”

Of interest for the present review, among the 300 “shoppable services,” (“a service that can be scheduled by a health care consumer in advance”) six behavioral health services are specifically listed among 70 services which must be provided, if provided by the hospital: individual psychological therapy at 30, 45, and 60 minute session lengths (standard procedure coding for these are 90832, 90834, and 90837), family therapy with or without the “identified” patient present (standard codes 90846, 90847), and group therapy (standard code 90853). Sites were reviewed for availability of consumer-searchable price information and the comprehensive file, with emphasis on these six specific services.

Method

During the last two weeks of July 2021, the websites of the three main hospitals in Madison, WI (SSM Health St. Mary’s, UnityPoint Meriter, UW Health University) were reviewed for availability of both the comprehensive machine readable and consumer friendly listings of shoppable services, with emphasis on the six behavioral health services. A checklist was designed for the site reviews, based on guidance provided by the Centers for Medicare and Medicaid Services (CMS) to hospitals for “10 Steps to Making Public Standard Charges for Shoppable Services.” Sites were reviewed for all six criteria. When available, prices listed for the specific behavioral health services are reported.

Results

None of the three hospitals are in full compliance with the transparency rule (See Table 1). Two hospitals were fully compliant with two of six criteria. One hospital was compliant with three criteria. All hospitals provided an apparently comprehensive machine readable file. Two hospitals provided the consumer-friendly searchable method for locating the charges for shoppable services, though these were in searchable formats and not provided in a straightforward list. 

Detailed reviews of each of the hospitals, including prices reported for the six behavioral health services are available here:

One of the hospitals provided a cost estimator page, but none of the six behavioral health services were returned with a search or an indication that the price was not able to be provided without calling. Only one hospital provided relevant notification of financial aid. Only one hospital provided clear communication about the location at which the shoppable service was provided, but included no indication of whether the pricing information was for in- or outpatient service (all of these behavioral health services may be provided both to outpatients and those hospitalized). 

None of the hospitals provided quality of care information in the context of price transparency searches. None of the hospitals displayed information in languages other than English in the context of price searches. Please see the appended checklist reviews that provide details of results for each of the hospitals.

Meaningful price information was able to be obtained for two of the hospitals. One hospital (UW Health University Hospital) clearly provided the most detailed information, both via the shoppable search as well as through the machine readable file, though the latter required data extraction beyond likely typical consumer efforts. Prices for the six mandated-reportable behavioral health services were simply not available by a shoppable search for UnityPoint Meriter. Detailed comparison of prices may be seen in the individual checklist compliance reviews.

Price variability is evident when prices are comparable. For example, the price for a 60 minute individual therapy session varied from $478.16 (via the machine readable data, not easily located by the consumer), to $537 via a shoppable search at a second hospital. Family therapy varied from $350.08 to $366. Group therapy varied from $142 to $344.77.

Additionally, discrepancies are common among prices listed in consumer-facing shoppable searches and the machine readable databases. For example, the shoppable search for UW Hospital shows a charge of $537 for a 60 minute individual therapy session, and a charge of $474 in the machine readable database. A charge of $603 is reported for this same service in the machine readable database, annotated with an unexplained designation which appeared to suggest a different price depending on the type of clinician providing the service. Differences in consumer-facing charges and internal databases could certainly leave consumers surprised when a billed amount is different from the amount found with a shoppable search.

When available (UW Hospital), prices shown as “discounted consumer price” were lower than consumer shoppable search, for all six behavioral health services. The discounted price is the price charged to consumers paying “out of pocket,” without insurance. For three services (individual therapy at 30, 45, and 60 minutes) the “discounted cash price” shown in the machine readable data base was lower than the prices shown in the consumer-facing shoppable search. For three services (family therapy with and without patient, group therapy), prices in the machine readable database were higher than those reported in the consumer shoppable search. These discrepancies additionally render it uncertain the actual price consumers would be charged for any of these six behavioral health services if purchasing the service without using insurance.

Discussion

On an economic basis alone, it would seem that local hospitals and hospitals across the country would want to come into full compliance soon. The current maximum potential fine for noncompliance with the price transparency rules is $300 per day up to $109,500 for hospitals with more than 30 beds. CMS has proposed increasing fines up to $2 million annually for Medicare-enrolled hospitals, potentially effective as of 1/1/2022. 

Beyond the economic incentive, the public health/public service dimensions also seem clear. Psychotherapy is a much needed health care service, with chronically insufficient access, particularly for marginalized populations (Herz & Gaba, 2019). Psychotherapy via tele-media skyrocketed during the pandemic, particularly for behavioral health, likely due at least in part to eased access for some populations (Campion, Ommen, Sweet, et al., 2021). At some point, consumers might well want to return to seeing their clinician in person. Whether in person or via tele-visits, the main purpose of promoting price transparency — improving consumer knowledge and choice — is undermined to the extent consumer-accessible information remains unavailable, obscured, or less than fully accurate. Secondary purposes such as shifting greater strength to consumers to negotiate reasonably expected prices, and to increase competition among hospitals and community based clinicians offering similar services, also remain incomplete.

References

Herz, G. & Gaba, C. (2019). Health systems issues and the underserved. In
Bringing Psychotherapy to the Underserved (pp. 3–24). Oxford
University Press. https://www.oxfordclinicalpsych.com/view/10.1093/med-psych/9780190912727.001.0001/med-9780190912727-chapter-1.

Campion, F., Ommen, S., Sweet, H., Shah, N., Rabson, B., Dougherty, N.,
Goldsack, J., Sylvester, P., Jones, K., Burgman, A., McIntosh, N.,
Sangaralingham, L., Jiang, D., McGinn, J., Rojas, R., Suther, T.,
Anderson, B., & Halamka, J. (2021). COVID-19 Telehealth Impact Study:
Exploring One Year of Telehealth Experimentation. Telehealth and
Medicine Today. https://telehealthandmedicinetoday.com/index.php/journal/article/view/280/432.

Medicare and Medicaid Programs: CY 2020 Hospital Outpatient PPS Policy
Changes and Payment Rates and Ambulatory Surgical Center
Payment System Policy Changes and Payment Rates. Price
Transparency Requirements for Hospitals To Make Standard Charges Public. (2019, November 27). Federal Register. https://www.federalregister.gov/documents/2019/11/27/2019-24931/medicare-and-medicaid-programs-cy-2020-hospital-outpatient-pps-policy-changes-and-payment-rates-and.


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